Lower Lid Internal Blepharoplasty

Procedure: The procedure in this video demonstrates a cosmetic lower lid internal blepharoplasty. Introduction: Lower lid internal blepharoplasty is a surgical technique used to address cosmetically unacceptable lower eyelid fat prolapse. This procedure can smooth facial contours between the eyelid and cheek, which can help restore a more youthful appearance. It can also be easily combined with other eyelid procedures to address periorbital aging changes. The internal, transconjunctival approach allows for access to the fat pads without incision of the skin or orbicularis muscle. Indications/Contraindications: Indications for lower lid blepharoplasty include prolapsed lower lid fat pads. The internal approach is particularly beneficial for those who do not have concurrent lower lid dermatochalasis or lower lid malposition. Contraindications include conjunctival cicatricial disease, skin infection or malignancy, or recent filler use.   Materials/Methods: Key instruments include scleral shell, a Bovie cautery with a Colorado needle tip, a bipolar cautery, Westcott scissors, hemostat, Desmarres retractor, and suture (4-0 silk). Important steps include lower lid traction sutures, a curvilinear conjunctival incision 3-4mm below the inferior tarsal border and then an incision to open the septum, followed by excision of prolapsed lower eyelid fat with a clamp, cut, and cauterize technique.  Results: A successful lower lid blepharoplasty will improve aesthetic appearance by improving lower lid contour. Conclusion: Lower lid internal blepharoplasty is an effective surgical procedure to address cosmetically unacceptable prolapsed lower lid fat pads.

Lower lid internal blepharoplasty is a surgical technique used to address cosmetically unacceptable lower eyelid fat prolapse. This procedure can smooth facial contours between the eyelid and cheek, which can help restore a more youthful appearance. It can also be easily combined with other eyelid procedures to address periorbital aging changes.   There are two approaches to lower lid blepharoplasty: the internal transconjunctival approach and the transcutaneous approach. Here we demonstrate the internal approach, which avoids a skin and orbicularis muscle incision and therefore reduces the risk of denervation or lid retraction.   Indications for lower lid internal blepharoplasty include prolapsed lower lid fat pads. The internal approach is particularly beneficial for those who do not have concurrent lower lid dermatochalasis or lower lid malposition. Contraindications include conjunctival cicatricial disease, skin infection or malignancy, or recent filler use.  

Instrumentation/Setup: Key instruments include scleral shade, a Bovie cautery with a Colorado needle tip, a bipolar cautery, Desmarres retractor, Westcott scissors, hemostat, and suture (4-0 silk).   Pre-operative workup: A thorough medical history and complete eye examination with slit lamp biomicroscopy should be performed, with special attention to the structure and function of the eyelids, and the conjunctival and corneal surface. Pertinent history should include dry eye symptoms, or history of prior facial surgery, facial trauma, or fillers. The lower eyelid should be assessed for laxity and malposition, such as retraction, ectropion, or entropion. The conjunctiva should be inspected for cicatricial changes.   Anatomy and landmarks: Understanding lower eyelid anatomy is critical for this procedure. In particular, the inferior oblique muscle runs through the potential space between the nasal and central fat pads. Care should be taken to avoid inadvertently damaging this muscle. The lateral fat pad can often be overlooked as it is more fibrous and larger than the other fat pads, so particular attention in this region will ensure an aesthetically pleasing outcome.   Detailed steps to procedure: Proparacaine is instilled onto the ocular surface. Under the benefits of MAC anesthesia, local anesthetic is infiltrated subcutaneously and subconjunctivally into the lower eyelid. The patient is prepped and draped in normal sterile fashion for oculoplastic surgery. A corneal protector is placed.   A 4-0 silk traction suture is placed through the lower eyelid margin through the tarsus. Additional traction with fingertips on the lower lid is applied to ensure that the cautery does not buttonhole the skin. A transconjunctival incision is made 3 to 4 mm below the inferior border of the lower eyelid tarsus with a Bovie cautery with a Colorado tip on cut mode through the conjunctiva and eyelid retractors in a curvilinear fashion. A second 4-0 silk traction suture is placed through the lower edge of the conjunctiva. The anterior face of the orbital septum is incised with the Bovie. A Demarres retractor is used to visualize the central, medial, and lateral fat pads of the lower eyelid. Blunt dissection with a hemostat is used to prolapse the orbital fat. A lobule of prolapsed fat is clamped with the hemostat, excised with a Westcott scissors, and then the stump of fat in the clamp is cauterized using bipolar cautery.  Additional local anesthetic can be injected directly into the fat pad when the patient experiences discomfort.   The Desmarres retractor is removed and the lower eyelid is inspected to ensure that the appearance is smooth and symmetric. When there are no undesired areas of fat prolapse remaining, the corneal protector and traction sutures are removed.  Antibiotic ointment is placed onto the ocular surface.   The procedure can then be repeated on the contralateral eye. It can be useful to keep the removed fat lobules in anatomic position on a surgical towel to serve as a guide.

The goal of a lower lid internal blepharoplasty is to improve lower lid contour. Post-operatively, there should be improvement or resolution of lower lid fat prolapse. Potential negative outcomes include post-operative complications such as infection or hematoma, eyelid retraction, lower eyelid hallowing, asymmetry, or ocular surface irritation or abrasions, or residual fat prolapse.  

Lower lid internal blepharoplasty can be used to address cosmetically unacceptable prolapsed lower lid fat pads. The internal approach avoids a skin and orbicularis muscle incision compared to the transcutaneous approach, and therefore reduces risk of denervation and lower lid retraction. It is a smaller incision, which may be beneficial for healing but provides more limited exposure of the fat pads during the procedure compared with an external approach. This procedure can also be combined with other eyelid procedures.   Important steps are described above in detail and include: careful pre-operative planning, adequate exposure with traction sutures, a curvilinear incision 3-4mm below the inferior tarsal border, and a clamp, cut, cauterize technique for removal of fat pads. Caution should be taken to avoid the inferior oblique muscle, between the nasal and central fat pads, and to fully address the lateral fat pad, which can be more fibrous than the others and a common area for residual prolapsed fat.   Lower lid internal blepharoplasty is an effective surgical procedure that helps to restore a smooth facial contour between the eyelids and cheek and improves the cosmetic appearance of the lower eyelids.

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